Mask Mouth - A new malady affecting oral health in the COVID era.
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Annals of International Medical and Dental Research
E-ISSN: 2395-2822 | P-ISSN: 2395-2814
Vol-7, Issue-4 | Jul-August, 2021
Page no- 16-22 | Section- Research Article (Dentistry)
“Mask Mouth‟- A new malady affecting oral health in the COVID era.”
Dr. Pooja Muley-Itke1*
1M.D.S.,Consultant, Oral Abstract
physician and maxillofacial
Radiologist, Aurangabad, Background: Presently the use face masks has become the need of
Maharashtra, India. Mail the hour due to the severe acute respiratory syndrome coronavirus 2
IDpoojamuley.31@gmail.com. (SARS-CoV-2) pandemic. Although the use face mask protects the
Orcid Id: 0000-0002-5258-5659 user from SARS-CoV-2 infection, it has certain adverse effects. One
*Corresponding author. of the new and recently noticed side effect is on the oral health of the
wearer known as „Mask Mouth‟. This consist of symptoms like
caries, gingivitis, halitosis, candidiasis and angular cheilitis. In this
article, a systematic review was done, where comprehensive, critical
Received: April 2021 and objective analysis of the current knowledge regarding adverse
Accepted: May 2021 effects of using face mask on the oral health was reviewed. It was
observed that prolonged use of mouth mask can cause dryness of
mouth as well as bring about a change in the oral microflora and
have an impact on overall oral health. Mask mouth can be prevented
by maintaining proper oral and mask hygiene, avoiding mouth
breathing and staying hydrated.
Keywords: COVID 19, SARS Cov 2, Mouth Mask, Oral Health, Adverse Effects
INTRODUCTION
Key Messages:
This article deals with a newly noticed The outbreak of Severe Acute Respiratory
phenomenon-mask mouth which is caused Syndrome Coronavirus 2 (SARS-CoV-2)
due to excessive and improper use of face pandemic has generated a global health crisis
mask in this COVID era. Very smaller that has had a deep impact on the way we
amount of data is available currently on this perceive our world and our everyday lives.
topic. In this review article we have discussed The risk of severe infection with the virus
this new occurrence and its implications. depends profoundly on physical factors of
the infected persons and the quality of the
medical system. The routes of transmission of
SARS-CoV-2 include direct transmission
(droplet, e.g. cough, sneeze) and contact
transmission (contact with oral, nasal, and
16
Copyright: ©The author(s), published in Annals of International Medical and Dental Research, Vol-7, Issue-4. This is an open access article
under the Attribution-NonCommercial 2.0 Generic (CC BY-NC 2.0) license. (https://creativecommons.org/licenses/by-nc/2.0/)
Annals of International Medical and Dental Research
E-ISSN: 2395-2822 | P-ISSN: 2395-2814
Vol-7, Issue-4 | Jul-August, 2021
Page no- 16-22 | Section- Research Article (Dentistry)
eye mucous membranes). The presence of used to find potentially eligible
SARS-CoV-2 in the environment of COVID- articles.Recent and updated articles were
19 patients therefore reinforces the belief that included. Since this is a very new topic (mask
fomites play a role in transmission of SARS- mouth), no scientific articles were found.
CoV-2; however, the relative importance of Therefore articles related to its aetiology
this route of transmission compared to direct (dryness of mouth, mouth breathing, etc.),
exposure to respiratory droplets is still adverse effects of using face mask and its
unclear. Thus wearing of face masks has prevention were considered.PRISMAstudy
become necessary and ubiquitous, not only in selection flowchart is included to explain the
hospitals but also in the community.[1] process of article selection. (Figure 1)
Even though the use face mask protects the
user from SARS-CoV-2 infection, it has
certain adverse effects like headaches,
difficulty in communication, eye discomfort,
breathlessness, impaired cognition, skin
breakdown, acne. One of the new and
recently noticed side effect is on the oral
health of the wearer. A new term has been
coined for this phenomenon – „Mask Mouth‟.
Dentists all over the world have started to
notice increase in patients with complaints of
halitosis, gingivitis, ulcers and caries. It has
been reported that there is inflammation in
patient‟s gums that have been healthy
forever, and caries in people who have never
had them before. All these symptoms are
being linked to the excessive and improper
use of face mask. These are short term
problems, but they may lead to severe ones if
left unnoticed and untreated. In this article
we will see this new phenomenon, its
aetiology, its implications and prevention.
MATERIALS AND METHODS
Figure 1: PRISMA study selection flowchart
DISCUSSION
The current study is asystematic review,
where comprehensive, critical and objective
Mask mouth is triggered by covering mouth
analysis of the current knowledge regarding
for longer periods of time which increases
adverse effects of using face mask on the oral
dryness of the mouth. Also there is an
health is reviewed. Articles were searched in
increased incidence of mouth breathing when
online databases like PubMed, Science Direct,
using mask. Mouth breathing causes dryness
Springer link, DOAJ(Directory of Open
of mouth and build-up of disease causing
Access Journals) and Google scholar were
17
Copyright: ©The author(s), published in Annals of International Medical and Dental Research, Vol-7, Issue-4. This is an open access article
under the Attribution-NonCommercial 2.0 Generic (CC BY-NC 2.0) license. (https://creativecommons.org/licenses/by-nc/2.0/)
Annals of International Medical and Dental Research
E-ISSN: 2395-2822 | P-ISSN: 2395-2814
Vol-7, Issue-4 | Jul-August, 2021
Page no- 16-22 | Section- Research Article (Dentistry)
microflora in the mouth. Moreover people‟s to caries has been placed in correlation with
tendency to drink less water while masked the entry of air through the mouth and the
up which has added to the widespread regular intake of fermentable carbohydrates,
dehydration. Using unclean mask also add to resulting in the formation of plaque mostly
the chances of infection. We know that composed of acid-forming and acid-tolerable
mouth receives a greatest exposure to airflow species, such as Streptococcus mutans (S.
during mouth breathing. Surface mutans) and Lactobacilli.[5] A study by
dehydration and reduced salivary flow Mummolo, et al demonstrates that mouth
occurs because of this and, subsequently, the breathing late adolescents and young adults
gingival inflammation and irritation could be have a higher risk to develop S. mutans,
related to it.[2, 3]When salivary function is compared with the control subjects, and
diminished, there is more risk of patient‟s increase of plaque index in a period of 6
developing caries, gingivitis, halitosis and months. [6] Nascimento et al. reported that
having diseases such as candidiasis than significantly higher number of initial lesions
there is in patients who have normal salivary in all teeth was observed in the mouth
flow rates (SFRs).[4](Figure 2) breather group. [7]In another study it was
observed that levels of Streptococcus mutans
and Lactobacilliare higher in patients with
hypo salivation. [8]These findings suggest that
dryness of mouth and mouth breathing due
to wearing face mask might be one of the
factors related to the severity of dental caries.
Plaque Index
We know that dryness of mouth causes
decrease in salivary rate and in turn causes
increase in plaque formation. It wasobserved
that the mouth breathing subjects seem to be
predisposed to develop a higher plaque index
(PI) compared with healthy subjects.[6]This
result is in accordance with a previous case-
control study performed on adults with
asthma, in which a higher plaque score was
found among the asthmatics subjects (mostly
oral breathers) compared with control
subjects.[9] A reduction of buffering capacity
of saliva and its flow rate was also
Figure 2: Pathophysiology of mask mouth observed.[6] Hence we can say that using
mouth mask can be a factor causing increase
Implications of „Mask Mouth‟ in PI and in turn leading to gingivitis and
dental caries.
Dental Caries- Gingivitis
As we have seen using face mask causes Patients with chronic mouth breathing suffer
increase in mouth breathing. Predisposition from dry mouth which may result from
18
Copyright: ©The author(s), published in Annals of International Medical and Dental Research, Vol-7, Issue-4. This is an open access article
under the Attribution-NonCommercial 2.0 Generic (CC BY-NC 2.0) license. (https://creativecommons.org/licenses/by-nc/2.0/)
Annals of International Medical and Dental Research
E-ISSN: 2395-2822 | P-ISSN: 2395-2814
Vol-7, Issue-4 | Jul-August, 2021
Page no- 16-22 | Section- Research Article (Dentistry)
surface dehydration that eventually association was observed between reduced
predispose to oral infection and progressive SFRs and increased Candida counts.[13]
gingivitis.[10] Studies demonstrated that Angular Cheilitis and Ulcers
mouth breathing may cause an increase in Prolonged use of face mask creates a warm
susceptibility of gingival inflammation also moist environment on surrounding skin of
indicate that whole mouth exhibits highly mouth which is a perfect condition for
gingival inflammation not confined to bacteria to flourish and grow. This
anterior region in mouth breathing overgrowth of bacteria can produce angular
individuals. [7, 8] cheilitis, cracking and ulcers at the corner of
the mouth. (Figure 3)
Halitosis
Most of the patients having mask mouth
complain about halitosis, also known as
„mask breath‟. We know that the posterior
portion of the tongue‟s dorsum, where most
malodour originates, is often covered by a
layer of debris comprising cellular and non-
cellular components and tongue coating
plays an important role in increasing volatile
sulphur compounds concentration in mouth.
[11]An increase in severity of oral malodour in
habitual mouth breathers was seen with a
highly significant association. Oral dryness is
the primary cause of oral malodour in such
cases. [11]Decrease in salivary flow rate and
decreased water intake increases its severity.
Figure 3: Pictorial representation of implications
Candidal Infection of mask mouth
Saliva plays a significant role in oral
homeostasis. It contains antimicrobial
proteins such as lysozyme, lactoperoxidase, Prevention of „Mask Mouth‟:
immunoglobulins, histatins and lactoferrin. Wearing a face mask while stepping out has
Histatins have potent antifungal activity and become a norm and an inevitable part of our
there is also some evidence that salivary IgA lives. In today‟s times the benefits of wearing
inhibits oral adhesion of Candida albicans. masks outweigh the adverse effects. Likewise
[12]Oral dehydration due to use of mask, may the adverse effects can be easily prevented by
alter the oral microbiota and increase the risk following certain principles like -
for opportunistic infections, such as Mask etiquette
candidiasis. Dry mouth and decreased 1. Use proper technique to wear mask.
salivary rate can be a predisposing factor of Wearing clean mask, if possible
developing cadidal infection. According to a changing mask every 6 hours (if using
study conducted by Nadig et al, it was found cloth mask).
that there is statistically significant 2. Avoiding mouth breathing while
wearing mask. Health experts
19
Copyright: ©The author(s), published in Annals of International Medical and Dental Research, Vol-7, Issue-4. This is an open access article
under the Attribution-NonCommercial 2.0 Generic (CC BY-NC 2.0) license. (https://creativecommons.org/licenses/by-nc/2.0/)Annals of International Medical and Dental Research
E-ISSN: 2395-2822 | P-ISSN: 2395-2814
Vol-7, Issue-4 | Jul-August, 2021
Page no- 16-22 | Section- Research Article (Dentistry)
encourage to breathe in through their electric toothbrush brush including
nose and exhale through their mouth. tongue and the sides of cheeks.
The mouth is better for exhaling and 2. Use of mouthwashes at least once a
allows the body to expel air more day is recommended. Patients with
efficiently. dry mouth problems should avoid
3. Limiting circumstances: Use of mouth rinses containing high
facemasks should be restricted to concentration of detergent
higher risk circumstances, including components which reduce the
crowded, indoor spaces, where substantively of the agent and
physical distancing is not possible, worsen the dry mouth effect. Using
e.g. public transport chlorhexidine mouthwash highly
clinically significant for prevention
4. Frequent mask-free work breaks to be
of caries and plaque formation. [20]
incorporated into work shifts to allow
3. Flossing twice a day is
for shorter duration of mask use and
recommended.
reduction of PPE exposure.[15,16]
Dental procedures-Preventive fluoride
5. Use of improved mask design with a application, [11]prescribing 10%
focus on safety, comfort, and chlorhexidine varnish, scaling, pit and
[21]
tolerability.[16] fissure sealants can help in preventing
mouth mask.
Preventative measures such as applying
Avoiding-High sugar diet,
moisturizers, emollients, and barrier
overconsumption of caffeine, alcohol and
creams to prevent skin breakdown.[17]
smoking.
Caution should be taken that dressings,
Patient awareness- Last but not the least
moisturizers, and lotions do not interfere
making the patients aware about the
with the seal of the mask thereby causing
„mask mouth‟ is very essential to prevent
decreased protection against COVID-19
its implications. (Figure 4)
particles. Prevention of headaches and
impaired cognition by frequent short
breaks, neck massage, increased
hydration especially before start of the
shift, alternating between surgical and
N95 masks (if possible) and wearing a
mask that fits one‟s face best is
recommended.[18]
Drinking more water throughout the day-
Frequent consumption of water helps to
stimulate saliva production, reduce
chances of dry mouth and help in caries
prevention.[19]
Figure 4: Mask Mouth at a glance
Oral hygiene practices
1. Patients should brush their teeth
carefully 2 or 3 times a day with
either a manual toothbrush or an
20
Copyright: ©The author(s), published in Annals of International Medical and Dental Research, Vol-7, Issue-4. This is an open access article
under the Attribution-NonCommercial 2.0 Generic (CC BY-NC 2.0) license. (https://creativecommons.org/licenses/by-nc/2.0/)Annals of International Medical and Dental Research
E-ISSN: 2395-2822 | P-ISSN: 2395-2814
Vol-7, Issue-4 | Jul-August, 2021
Page no- 16-22 | Section- Research Article (Dentistry)
CONCLUSION avoided in current times. A positive aspect
about the mouth mask is that it can be easily
The situation of the current COVID-19 prevented and treated. So it is the need of the
pandemic is very different from that of the hour to act fast and save the population from
“parachutes for leaping out of aeroplanes”, in the long term effects of „Mask Mouth‟! But
which the aspects of harm and prevention are presently there is insufficient data to quantify
easy to define. It is necessary to study the all of the adverse effects that might reduce
complex interactions that may be working the acceptability, adherence, and
between positive and negative effects of effectiveness of face masks. Urgent research
wearing mouth masks. Definitely the positive is also needed on various other symptoms
aspects of wearing a mouth mask prevail and implication of mouth mask.
over the adverse effects and its use cannot be
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Copyright: ©The author(s), published in Annals of International Medical and Dental Research, Vol-7, Issue-4. This is an open access article
under the Attribution-NonCommercial 2.0 Generic (CC BY-NC 2.0) license. (https://creativecommons.org/licenses/by-nc/2.0/)Annals of International Medical and Dental Research
E-ISSN: 2395-2822 | P-ISSN: 2395-2814
Vol-7, Issue-4 | Jul-August, 2021
Page no- 16-22 | Section- Research Article (Dentistry)
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Source of Support:Nil,Conflict of Interest: None declared
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Copyright: ©The author(s), published in Annals of International Medical and Dental Research, Vol-7, Issue-4. This is an open access article
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